Failure to Remove Discharged Resident's Narcotics Led to Missing Oxycodone
Penalty
Summary
The facility failed to ensure that narcotic medications were promptly removed from the medication cart following the discharge of a resident, resulting in the misappropriation of oxycodone tablets. The resident in question had been admitted for aftercare following joint replacement surgery and had a physician's order for oxycodone 5 mg as needed for severe pain. Upon discharge, the resident's oxycodone was not removed from the medication cart, and subsequent audits revealed that two blister packs containing a total of fifty-two oxycodone tablets, along with the associated disposition sheets, were missing. Multiple staff interviews and record reviews confirmed that the oxycodone remained in the medication cart after the resident's discharge, with several LPNs recalling counting the medication during shift changes. Despite facility practice that the DON would collect discontinued or discharged residents' narcotics, there was no policy specifying the timeframe for removal, and staff did not consistently notify the DON in real time. The medication and disposition sheets were last accounted for during the morning shift count, but were discovered missing during the DON's bi-monthly narcotic audit later that morning. The investigation included review of surveillance footage, staff interviews, and examination of medication administration records, which showed that only eight of the sixty oxycodone tablets received for the resident had been administered, leaving fifty-two unaccounted for. The facility's lack of a clear policy and inconsistent communication regarding the removal of narcotics after discharge contributed to the failure to secure the medication, resulting in its disappearance.